DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62645 (Rev. 07/08)
STATE OF WISCONSIN
CANCER AND CHRONIC DISEASES DRUG REPOSITORY PROGRAM RECIPIENT RECORD
Completion of this form meets the requirement of Wisconsin Administrative Code HFS 148.07(3) for dispensing drugs or medical supplies to recipients who meet the eligibility requirements of HFS 148.05. Questions about completion of this form may be directed to 608-266-5388.
Date Received
Name Recipient (Print or type.)
NOTE: The pharmacy may place a copy of the label on this form in lieu of entering the following information.
Name Medication Medication Strength Expiration Date Quantity Received
I attest that I am a Wisconsin Resident and that I understand that the medication I am receiving has been donated and has potentially been stored in a non-controlled environment. I understand that the pharmacy, pharmacist, and manufacturer cannot be held liable for problems with this medication that has been accepted for donation and dispensed in good faith.
SIGNATURE Recipient
Date Signed